Isr J Psychiatry Relat Sci - Vol.

53 - No 3 (2016)

Cannabis and Alcohol Abuse Among First Psychotic

Episode Inpatients
Gregory Katz, MD,1 Yehuda Kunyvsky, MD,1 Tzipi Hornik-Lurie, PhD,2,3 Sergey Raskin, MD, MHA,1
and Moshe Z. Abramowitz, MD, MHA1
1
The Jerusalem Mental Health Center, Jerusalem, Israel
2
The Falk Institute for Mental Health Studies, Kfar Shaul Hospital, Givat Shaul, Jerusalem, Israel
3
Department of Emergency Medicine, Leon and Mathilde Recanati School for Community Health Professions, Faculty of Health Sciences,
Ben-Gurion University of the Negev, Beer-Sheva, Israel

Abstract Alcohol abuse and dependence were diagnosed by

Background: Psychoactive substance abuse, which
includes abuse of alcohol and street drugs, is common
among first-episode psychosis patients, but the
prevalence of cannabis abuse is particularly high.
However, there have been very few reported studies
concerning the occurrence of psychoactive substance
abuse among first-episode psychotic individuals using
standard toxicological testing. We study the prevalence
of cannabis and alcohol abuse among first-psychotic-
episode inpatients as well as compare the demographic,
diagnostic, and psychopathological profiles of substance
abusers versus nonusers.
Methods: Subjects were recruited from the
Jerusalem Mental Health Center between 2012 and
2014. Ninety-one consecutively admitted psychiatric
patients diagnosed using the DSM-IV criteria with
a first psychotic episode due to schizophrenia,
schizophreniform disorder, bipolar disorder, brief
psychotic episode, and psychosis NOS disorder entered
the study. The diagnoses of schizophrenia (all types),
psychosis NOS disorder, brief psychotic episode, and
schizophreniform disorder were categorized as “only
psychosis” and those of bipolar disorder manic episode
with psychotic features (congruent and incongruent)
and severe depression with psychotic features were
categorized as “predominantly affective symptoms.”
Urine tests for tetrahydrocannabinol (THC) were
performed during the first 48 hours of admission, and
likewise self-report questionnaires were administered.
The study was supported by the Research Grant of the Israel
Anti-Drug Authority
self-report.
Results: Of the 91 subjects in the study, 49 (53.8%) did not
abuse any illegal psychoactive substance. Twenty patients
(22%) abused only cannabis; 14 (15.4%) abused cannabis
and another psychoactive substance; 54 (59.3%) of the
subjects reported no alcohol abuse; 33 (36.3%) reported
occasional drinking (between two and ten times a month);
and 4 (4.4%) reported continuous repeated drinking
(more than ten times a month). There was no correlation
between the demographic characteristics and the abuse
of cannabis. Two-thirds of the “predominantly affective
symptoms” subjects were positive for THC, whereas
only a third of the “only psychosis” subjects screened
positive for THC.
Conclusions: The percentage of cannabis and alcohol
abuse in the study population is much higher than one
would expect to see in the general Israeli population
(according to the Knesset Research Department
7.6–10.2% of the adult Israeli population abuse
cannabis). Different patterns of cannabis abuse among
“predominantly affective” and “psychotic only” patients
may lend credence to the preferential use of a specific
substance per diagnosis.

Address for Correspondence: Dr. Gregory Katz, The Jerusalem Mental Health Center, Givat Shaul Beith, Jerusalem 91060, Israel
  ngkatz60@gmail.com

10
 Gregory Katz et al.
Introduction
Substance abuse among psychiatric inpatients is a widely
recognized problem although the precise extent and ori-
gin of the phenomenon is still unclear. In the large-scale
CATIE study done in the U.S., of the 1,460 participants,
23% abused substances and 37% had a substance abuse
disorder (1). In a 2008 study in Israel, 470 consecutively
admitted patients were evaluated (250 patients in the
mental health center and 220 in the psychiatric department
of a general hospital). Lifetime prevalence of drug abuse
was found to be 24%, active abuse of substances (during
the previous month) was 17.3%, and 28.2% of the active
abusers used two or more substances (2).
Comorbid abuse has profound implications for the
course and treatment of schizophrenia. Individuals diag-
nosed with schizophrenia who abuse drugs and alcohol tend
to have poorer outcomes than their non-substance-using
counterparts and substance abusers in the general popula-
tion (3, 4). Cannabis is one of most abused illegal substances
in the general population. Marijuana was found to be the
most commonly used illicit drug in the United States (5).
Recent emphasis has been on the possible causal links
between cannabis and psychosis (6-8). In meta-analyses
of the rate of cannabis abuse in general clinical samples of
patients with schizophrenia (all types), the median current
rate of cannabis abuse was 16.0% and the median lifetime
rate was 27.1% (9).There is intense debate in the literature
as to whether schizophrenia with pre-onset cannabis abuse
disorder may be a distinct entity with specific features or
whether cannabis abuse disorder can precipitate schizo-
phrenia in genetically vulnerable subjects (10-12).
Psychoactive substance abuse, including abuse of alcohol
and street drugs, is common among first-episode-psychosis
patients, but the prevalence of cannabis abuse is particularly
high and in some studies reached a rate of about 75.0% (13).
Barnett et al. (14) studied lifetime and current substance
abuse in an epidemiologically representative sample of
people experiencing a first episode of clinically relevant
psychosis in England. Results indicated that substance
abuse among individuals with first-episode psychosis was
twice that of the general population; cannabis abuse was
reported in 51% of patients. Age at first use of cannabis as
well as cocaine, ecstasy, and amphetamines was significantly
associated with age at first psychotic symptom.
There is a high prevalence of substance abuse among
persons suffering from early psychosis, with cannabis and
alcohol featuring prominently (15). Contrary to other
studies, in the prospective multisite study of people experi-
encing a first episode of psychosis carried out at four early
intervention services in Ontario, Canada (16), prevalence
rates between the first-episode sample and the general
sample for lifetime cannabis use was similar (60% vs. 55%,
respectively). The results of a research project in Milan,
Italy, showed that 34.7% of first-episode schizophrenic
patients had a lifetime history of substance abuse. In mul-
tisubstance abusers, cannabis was the substance used most
frequently (49%), followed by alcohol (13%), and cocaine
(4%) (17). In the above-mentioned meta-analysis (9), the
median rate of cannabis abuse disorder was markedly
higher in first-episode versus long-term patients (current
28.6%/22.0%, lifetime 44.4%/12.2%, respectively).
An association between psychoactive substance abuse
and subsequent risk of psychosis has been documented
repeatedly (6, 7, 18), but the interpretation of these data
can lead to ambiguity. First, premorbid personality traits
(i.e., early signs or symptoms of a mental disorder) might
have predisposed individuals both to developing a psy-
chosis and to seeking psychoactive substances. Second,
abuse of psychoactive substances may be secondary to
the emerging presence of a psychosis as a form of “self-
medication” for treating symptoms (19). The “common
factor” model proposes that psychiatric and substance-use
disorders frequently co-occur due to underpinning shared
biological, psychological, or social factors such as genetics,
family history, antisocial personality disorder, childhood
trauma, cognitive impairment, or low socioeconomic status
(20). “Bidirectional” models hypothesize that either of
the two disorders can increase vulnerability to the other
(21), whereas personality models posit that comorbidity is
related to individual differences in the stable trait-specific
personality variables that underlie affective outcomes, cop-
ing strategies, and subsequent risk for substance use (22).
Results of our previous study (23) suggested that can-
nabis can produce an antidepressive and anxiolytic effect
on psychotic and affective inpatients. This effect might
partly explain the high level of comorbidity of psychosis
and the exacerbation of certain manic symptoms in this
group of patients. However, this explanation hardly covers
all of the possible etiologies of the nature of comorbid
substance abuse.
The availability and reliability of urine toxicology makes
such a test a vital tool for optimal diagnosis and treatment
of mental patients who underreport substance abuse (24).
To the best of our knowledge, the occurrence of psycho-
active substance abuse among first-episode psychotic
individuals using standard toxicological testing in Israel
has not been reported.
11
 Cannabis and Alcohol Abuse among First Psychotic Episode Inpatients

abuse using Pearson’s chi-square and analysis of variance

Methods (ANOVA). Data analyses were performed using SPSS/PC
Ninety-one consecutively admitted psychiatric patients version 21.0. Two-sided tests of significance were used,
diagnosed with a first psychotic episode due to schizo- with an alpha set at 0.05 in all analyses.
phrenia, schizophreniform disorder, bipolar disorder,
brief psychotic episode, or psychosis NOS disorder were
recruited between the years 2012 and 2014 from the inpa- Results
tient population of the Jerusalem Mental Health Center, The distribution of the study population (n = 91) by demo-
which comprises a catchment area of approximately one graphics, DSM diagnostic criteria, and current abuse of
million people. In order to facilitate further understanding cannabis (urine assay and self-report) and alcohol (self-
of patterns of substance abuse in subgroups, schizophrenia report) is shown in Table 1. Among the study population
(all types), psychosis NOS disorder, brief psychotic episode, 53 subjects (58.2%) did not use cannabis and 49 (53.8%)
and schizophreniform disorder were categorized as “only were negative for any illegal substances (negative self-
psychosis” and those of bipolar disorder manic episode report and urine assay); in 4 subjects (4.4 %) use of the
with psychotic features (congruent and incongruent) and substances was unclear. A total of 20 subjects (22%) used
severe depression with psychotic features were categorized only cannabis; 14 (15.4%) used cannabis and another
as “predominantly affective symptoms.” The patients were psychoactive substance; 54 (59.3%) reported no alcohol
diagnosed by two certified psychiatrist (G. K. and Y. K.) use; 33 (36.3%) reported occasional drinking (between two
in 2-day period after admission. Psychosis and cannabis
and alcohol abuse were diagnosed using SCID-IV (25). Table 1. Characteristics of Respondents, Current THC Abuse
& Alcohol Use
Urine tests for THC, amphetamine, methamphetamine,
Total
and natural and synthetic opiates were performed during
the first 48 hours of admission using Sure Step TM kits Variables n %
(Applied Biotech, Inc., San Diego). Active abuse of can- Gender Male 76 83.5
Female 15 16.5
nabis (during the last month prior to hospitalization) was
registered according to urine tests and/or self-reports, and Age (groups)  ≤21 31 34.1
22-26 28 30.8
life-time abuse according to self-reports only. Alcohol abuse 27+ 32 35.2
and dependence (active and life-time) were diagnosed by Mean (sd) 27.1 (9.2)
psychiatric history and self-report. In cases of combined Education ≤10 27 29.7
cannabis-alcohol abuse (or dependence) cannabis was (groups) 11-12 51 56.0
13+ 13 14.3
defined as the leading substance of abuse. Mean (sd) 11.5 (2.4)
The study hypothesis was that there is an association
Occupation Professional 7 7.7
between the occurrence of a first psychotic episode with Blue collar 16 17.6
cannabis abuse as well as with certain psychopathologi- Non-professional 26 28.6
cal features. Student 8 8.8
Unemployed 27 29.7
Unclear 7 7.7
Ethical Considerations
Marital Status Married 24 26.4
Institutional Review Board approval was received from Unmarried 67 73.6
the Jerusalem Mental Health Center. Informed consent Diagnosis Schizophrenia 6 6.6
was obtained according to the Helsinki declaration. according to Acute psychotic episode 70 76.9
Patient anonymity was maintained using codes for all DSM-4 Mania with psychotic features 12 13.2
Severe depression with
forms and test results. psychotic features 3 3.3
THC current No use 53 58.2
Statistical Analysis abuse according Use only THC 20 22.0
Lambda was calculated in order to examine bivariate to self-report Use THC & other drugs 14 15.4
associations between positive self-report of cannabis & urine Unclear 4 4.4

use and positive urine testing for THC. Additionally, Alcohol use No use 54 59.3
according to 2-10 times per month 33 36.3
demographics and DSM diagnosis were assessed for sig- self-report More than 10 times per month 4 4.4
nificant bivariate associations with cannabis and alcohol

12
 Gregory Katz et al.

Table 2. The Association Between Self-Reported and Urine

use) is shown in Table 3. No correlation was found between
Testing for the Abuse of THC (n=87¥) demographic characteristics and the abuse of cannabis.
Urine For six patients occupation was not determined and for
Negative Positive
four participants the abuse of THC was uncertain.
(n=62; 73.1%) (n=25; 28.7%) However, we found a statistically significant association
n % n % λ between psychiatric diagnosis and active THC abuse (c2(1)
Self-report = 5.8; p < .05). A significantly high percentage (29.4%) of
No use (n=53; 60.9%) 53 60.9 0 0.0 λ =.695*** THC-positive subjects was diagnosed with “predominantly
Current use (n=34; 39.1%) 9 10.3 25 28.7
affective symptoms,” whereas among the THC negative
subjects that was the case for only 9.4%. Two-thirds (10 out
¥
For four participants using THC was not clear
***p< .001
of 15) of those with “predominantly affective symptoms”
were positive for THC, whereas only a third (24 out of 72)
and ten times a month); and 4 (4.4%) reported continuous of the “only psychosis” subjects screened positive for THC.
repeated drinking (more than ten times a month). Further, a statistically significant association was found
A cumulative 67% of the study population had a 3-year between alcohol use and a positive urine THC finding:
self-reported history of psychoactive substance abuse among cannabis abusers 76.5% were found to use alcohol,
predating the first psychotic episode. whereas only 20.8% of THC nonusers reported alcohol
Table 2 demonstrates the association between self-report use (c2(1) = 26.3; p < .001).
of cannabis abuse and positive urine testing for THC. Demographic characteristics of subjects with respect to
One of the most unexpected findings was the high rate of alcohol use, DSM diagnosis, and a THC use are shown in
agreement (89.7%) on cannabis abuse between self-reports Table 4. Interestingly, no association was found between
and objective toxicology tests (λ = .695; p < .001). gender, level of education, marital status, and DSM diag-
The association between demographic variables and the nosis and the use of alcohol. Age, as a categorical variable,
abuse of cannabis (with or without self-report of alcohol was found to be associated with alcohol use (c2(2) = 7.6;
Table 3. Characteristics of Respondents & Alcohol Use according to Categories of the Current Abuse of THC (n=87¥)
No use Use
Total n=53 n=34
Variables n=87¥ Column % Column % F/χ2
Gender Male 85.1% 79.2% 94.1% n.s
Female 14.9% 20.8% 5.9 %
Age (groups) ≤21 34.5 37.7 29.4 n.s
22-26 29.9 28.3 32.4
27+ 35.6 34.0 38.2
Mean (sd) 27.2 (9.4) 26.6 (9.4) 28.1 (9.4) n.s
Education (groups) ≤10 28.7 24.5 35.3 n.s
11-12 57.5 58.5 55.9
13+ 13.8 17.0 8.8
Mean (sd) 11.6 (2.3) 11.9 (2.2) 11.0 (2.5) n.s
Occupation# Professional 8.6 11.8 3.3 n.s
Blue collar 19.8 15.7 26.7
Non-professional 30.9 29.4 33.3
Student 8.6 13.7 0.0
Unemployed 32.1 29.4 36.7
Marital Status Married 25.3 28.3 20.6 n.s
Unmarried 74.7 71.7 79.4
Diagnosis according Only psychosis (schizophrenia, acute psychotic episode) 82.8 90.6 70.6 χ2=5.8*
to DSM-4
Predominately affective symptoms (mania with psychotic 17.2 9.4 29.4
features, severe depression with psychotic features)
Alcohol use according No use 57.5 79.2 23.5 χ2=26.3***
to self-report Current use 42.5 20.8 76.5
¥
For four participants using THC was not clear
#
For seven participants occupation was not clear
n.s=not significant; *p< .05; ***p< .001

13
 Cannabis and Alcohol Abuse among First Psychotic Episode Inpatients

Table 4. Characteristics of Respondents according to Categories of using Alcohol (n=91)

No use Use
Total n=54 n=37
Variables n=91 Column % Column % F/χ2
Gender Male 83.5% 79.6% 89.2% n.s
Female 16.5% 20.4% 10.8%
Age (groups) ≤21 34.1 42.6 21.6 χ2=7.6*
22-26 30.8 20.4 45.9
27+ 35.2 37.0 32.4
Mean (sd) 27.1 (9.2) 27.0 (9.4) 27.3 (9.2) n.s
Education (groups) ≤10 29.7 31.5 27.0 n.s
11-12 56.0 50.0 64.9
13+ 14.3 18.5 8.1
Mean (sd) 11.5 (2.4) 11.6 (2.6) 11.3 (2.1) n.s
Occupation # Professional 8.3 12.0 2.9 χ2=11.4*
Blue collar 19.0 12.0 29.4
Non-professional 31.0 32.0 29.4
Student 9.5 16.0 0.0
Unemployed 32.1 28.0 38.2
Marital Status Married 26.4 31.5 18.9 n.s
Unmarried 73.6 68.5 81.1
Diagnosis according to DSM-4 Only psychosis (schizophrenia, acute psychotic episode) 83.5 88.9 75.7 n.s

p < .05), the essential difference occurring in the younger
age group (18-21) in which there were fewer users than
no-users. However, no statistically significant difference
was found between the mean age of the “no use” of alcohol
group and the “use” group.
Another statistically significant relationship was found
between the type of occupation and the use of alcohol (c2(4)
= 11.4; p < .05). Approximately 60% of the “blue collar”
subjects used alcohol. It is also important to note that in
the group of alcohol users only 2.9% were with “profes-
sional” working background while in the “nondrinking”
group they accounted for 12.0% (c2=11.4). There were no
students among the alcohol drinking group.
Discussion
The abuse of psychoactive substances by psychotic indi-
viduals is well documented. However, there are many
fewer data concerning the abuse of alcohol and psychoac-
tive substances on admission due to an individual’s first
psychotic episode.
Our approach was to perform toxicological urine screen-
ing tests on 91 first-episode inpatients of the Jerusalem
Mental Health Center, in addition to administering ques-
tionnaires. To the best of our knowledge, this is the first
such study to be performed in Israel.
Ponizovsky et al. (26) have recently published findings
relating to a decrease in dual diagnosis of severe mental
illness and substance use disorders in Israel between 1996
and 2010 (e.g., dual diagnosis with drugs decreased from
8.2% in 1996 to 6% in 2010). However, that study was a
retrospective epidemiologic survey using data from the
Israel National Psychiatric Case Register and was not based
on a prospective inpatient sample using active question-
ing, self-reports, and urine assays. Our findings as to the
conclusions in that study suggest an underreporting of
abuse perhaps due to a nondisclosure of the abuse of illegal
substances and an underdiagnosis of abuse in the presence
of acute psychosis on the part of the admitting psychiatrist.
Our results regarding comorbidity rates between first
psychotic episode and cannabis/alcohol abuse are similar to
those of other studies that have been performed elsewhere
(27); however, the percentage of substance abusers in the
study population is higher than one would expect in the
general Israeli population (7.6%–10.2 % of adult Israeli
population)(28).
One of the most interesting points in our findings was
the fact that a cumulative 67% of the study population had
a 3-year self-reported history of psychoactive substance
abuse predating the first psychotic episode. Granted, there
may be a common genetic predisposition that increases the
risk that an individual will take psychoactive substances
or develop a psychosis (29). However, the fact that such
a significant percentage of the study population abused
psychoactive substances months, even years, prior to the
first episode demonstrates that the psychosis is not simply
a direct primary outcome of the abuse. Though psychotic
symptoms can indeed be seen in cases of psychoactive

14
 Gregory Katz et al.
substance intoxication and in cases of hallucinogen abuse,
the symptoms found in our inpatient sample cannot be
explained solely by the abuse.
Khantzian (30) has recently written that, “Notwithstanding
the absence of empirical evidence, clinical observations
(practice-based evidence) suggest that there is a consid-
erable degree of preference/specificity for an individual’s
drug-of-choice.”
We found an association between the DSM diagnosis
and the type of psychoactive substance abused. Two-thirds
(10 out of 15) of the “predominantly affective symptoms”
subjects were found to be positive for THC, whereas only
a third (24 of 72) of the “only psychosis” subjects were
using THC. This finding may indicate the preferential use
of a specific substance per diagnosis that Khantzian has
proposed. Other researchers, including Arendt, found some
evidence that cannabis is used as a means of self-medication
for problems controlling aggression, but there is no such
evidence for the self-treatment of (prior) depression (31).
Lynskey et al. (32) found that an individual’s vulner-
ability may explain the correlation among tobacco, alcohol,
and cannabis abuse. Such vulnerability was predicted
by the interaction of the individual with delinquent and
substance abusing peers.
The coexistence of cannabis and alcohol abuse is also
intriguing (33) and raises the question of whether there
is a common liability to the abuse of the two substances
or a common psychological basis.
The common liability model assumes that a common
factor is responsible in the use of both licit and illicit drugs.
Genetic factors and peer pressure may put an individual at
risk for using or abusing both legal and illegal substances,
including alcohol and cannabis.
Another explanation being considered is the “gateway
theory,” whereby a licit substance (tobacco or alcohol) may
serve as a gateway to cannabis abuse (34).
Although the abuse of alcohol can be found among all
types of people in all walks of life, our study population
demonstrated a high representation of patients with blue
collar background. These data correspond with published
results of the large-scale epidemiological studies that dealt
with the general population (35), twins (36), and some
minorities (37). The Australian National Survey of High
Impact Psychosis (SHIP) revealed an association between
alcohol abuse and low educational level among individuals
with psychoses (38). In a population of alcohol abusers,
individuals reporting a chronic course of major depres-
sive disorder were socioeconomically and educationally
disadvantaged (39).
Limitations of the study include the fact that since the
beginning of the study, there has been a sharp rise in the
abuse of synthetic cannabinoids (40), which were not
included in the original toxicology screen. This might
well serve to remind us that the significant percentage of
substance abusers among the study population is prob-
ably an underestimate. In addition, alcohol abuse was
based solely on patients’ self-report and psychiatric history.
Finally, the study was cross-sectional and the sample was
middle-sized. However, as our mental health center has a
catchment area of Greater Jerusalem (a population of close
to a million people), we believe that the respondents in
this study represent the general population. We propose
that similar studies be replicated on a larger scale and in
different venues to confirm our findings.
Conclusions
A significant percentage of individuals presenting with
psychosis were found to be using psychoactive substances/
alcohol. Because of the significant impact of psychoactive
substance abuse on the psychopathology, diagnosis, and
prognosis, we believe that a routine toxicology screen is
recommended in all first hospitalizations and that there
be a high level of suspicion for comorbid substance abuse
when diagnosing a first psychotic episode.
There may be a preferential use of the type of psycho-
active substance and the psychiatric symptomatology
manifested.
Moreover, in our study, we found that 34 individuals
(37.3%) had been taking cannabis alone or in combination
with other illegal psychoactive substances in the month
prior to their first episode. This finding would lead us
to believe that in many cases, substance abuse predates
the psychiatric flare-up.
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